***Remote and must live in the United States***
JOB DESCRIPTION
Job Summary
Responsible for leading, organizing and directing the activities of the Provider Appeals Unit that is responsible for reviewing and resolving provider complaints and communicating resolution in accordance with the standards and requirements established by the Centers for Medicare and Medicaid
KNOWLEDGE/SKILLS/ABILITIES
- Manages staff responsible for the submission/resolution of provider inquiries, appeals and grievances for the Plan. Ensures resolutions are compliant.
- Proactively assesses and audits business processes to determine those most effective and efficient at resolving provider problems.
- Serves as primary interface with stakeholders and business partners and ensures standard processes are implemented.
- Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements.
- Maintains call tracking system of correspondence and outcomes for provider appeals; oversees monitoring of each member submission/resolution to ensure all internal and regulatory timelines are met.
- Managing regulatory complaints
JOB QUALIFICATIONS
REQUIRED EDUCATION:
Bachelor's degree or equivalent experience
REQUIRED EXPERIENCE:
- Min. 6 years’ experience in healthcare claims review and/or member dispute resolution.
- 2 years leadership experience
- Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing).
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
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